放疗应用于骨与软组织肉瘤及传统与案例交互教学法的应用研究

目的探讨不同模式放疗应用于骨与软组织肉瘤患者的疗效及安全性并交流推广传统与案例交互教学法（LBL CBL）的经验。方法收集2019年10月至2021年12月南京大学医学院附属鼓楼医院肿瘤中心接受放疗的99例骨与软组织肉瘤患者资料。3例患者行术前新辅助放疗（45～50 Gy）；25例患者行术后放疗，包括22例术后辅助放疗（45～60 Gy），3例术后残留病灶放疗（45～60 Gy）；37例患者行免疫放疗（6～40 Gy）；33例患者行常规剂量姑息放疗（25～75 Gy）；1例患者行根治剂量放疗（54 Gy）。选择其中18例患者，采用LBL CBL ，对规培医生进行基础知识、模拟定位、靶区勾画、放疗计划评估、疗效评价、患者随访等方面的教学，并采用出科考试及调查表的方法评估教学效果和满意度。结果共81例患者进行疗效评价。3例（3/3，100%）术前新辅助放疗患者术后病理均提示肿瘤发生坏死。术后辅助放疗组平均随访时间10.5个月，3例（3/19，15.8%）疾病进展，包括1例全身转移，2例原位复发，16例（16/19，84.2%）未复发。术后残留病灶放疗组平均随访时间10.8个月，1例（1/3，33.3%）保持疾病稳定状态，1例（1/3，33.3%）部分缓解，1例（1/3，33.3%）疾病进展。免疫放疗组平均随访时间4.4个月，8例（8/31，25.8%）进展，20例（20/31，64.5%）疾病稳定，3例（3/31，9.7%）部分缓解。姑息放疗组平均随访时间7.1个月，4例（4/24，16.7%）进展，16例（16/24，66.7%）疾病稳定，4例（4/24，16.7%）部分缓解。免疫放疗组和常规剂量姑息放疗组3个月局部控制率分别为80.1%（17/21）、100.0%（18/18），6个月局部控制率分别为63.6%（7/11）、85.7%（12/14）。1例根治剂量放疗的患者随访时间为11.0个月，疗效评价为部分缓解。3～4级不良反应发生率较低。LBL CBL的授课方式受到放疗规培学生认可程度较高，出科考试成绩优良。结论放疗是骨与软组织肉瘤患者综合治疗的重要组成部分，大多数不良反应可耐受，且可提高疗效，改善患者的生活质量。对于放疗规培的研究生，采用LBL CBL更有利于其掌握骨与软组织肉瘤的特点和临床放疗技能。

Radiotherapy for bone and soft tissue sarcomas: Clinical analysis of 99 cases and the application of LBL-CBL teaching mode

Objective The aim of this retrospective study is to observe and know the safety and efficiency of different types of radiotherapy for treatment of bone and soft tissue sarcomas and to present our institutional experience in teaching radiotherapy for sarcomas. Methods Ninety-nine patients with bone and soft tissue sarcoma from October 2019 to December 2021 were treated with different types of radiotherapy. 3 patients were exposed to neoadjuvant radiation(45-50Gy), 25 patients were exposed to postoperative radiation, of which 22 received adjuvant radiation(45-60Gy), 3 received radiation for residual tumor after surgery (45-60Gy). 37 patients with advanced sarcomas were exposed to immunogenic dose radiation (6-40Gy), 33 patients with advanced sarcomas were exposed to conventional palliative dose radiation(25-75Gy),1 patient was exposed to radical dose radiation(54Gy). Lecture-based learning (LBL) and case-based learning (CBL) teaching method were applicated to improve resident doctors’ knowledge and skills for positioning, target delineation, evaluation of curative effect and follow-up with 18 cases. Students' knowledge and satisfaction were assessed by means of examinations and questionnaires. Results Data from 81 patients were analyzed. Pathological tumor necrosis was observed in all 3 patients(100%)who received neoadjuvant radiotherapy. Median follow-up time of adjuvant radiation was 10.5 months. Treatment failure occurred in 3 patients (3/19, 15.8%) including local recurrence in 2 patients and distant metastasis in 1 patient. Sixteen patients (16/19, 84.2%) did not have recurrence. Median follow-up time of residual tumor radiation was 10.8 months. One patient (1/3, 33.3%) achieved partial response, one patient (1/3, 33.3%) remained stable and one patient (1/3, 33.3%) developed local recurrence. Median follow-up time of immunogenic dose radiation was 4.4 months. Eight patients (8/31, 25.8%) progressed, twenty patients (20/31, 64.5%) remained stable and three patients (3/31, 9.7%) achieved partial response. Median follow-up time of conventional palliative dose radiation was 7.1 months. Four (4/24, 16.7%) patientsprogressed, sixteen patients (16/24, 66.7%) remained stable and four patients (4/24, 16.7%) achieved partial response. The 3-months local control rates of immunogenic dose radiation and conventional palliative dose radiation were 80.1% (17/21)and 100%(18/18). The 6-months local control rates were 63.6%(7/11) and 85.7%(12/14), respectively. The patient treated with radical dose radiotherapy was followed up for 11.0 months, and achieved partial response. Grade 3-4 side effects was low throughout all treatments. The teaching mode of LBL-CBL was popular among resident doctors, and the exam results are excellent. Conclusions Radiotherapy is an important part of comprehensive treatment of bone and soft tissue sarcomas. Good local control and toxicity profile were observed in this study. The LBL-CBL teaching mode is regarded more effective in clinical practice course of bone and soft tissue sarcomas radiotherapy.